ANNALS OF SURGERY

Vol. 225, No. 5, 459-471

C 1997 Lippincott-Raven Publishers
.:

I...

-I....::'

Major Bile Duct Injuries During

Laparoscopic Cholecystectomy
Follow-Up After Combined Surgical and
Radiologic Management
Keith D. Lillemoe, M.D.,* Scot A. Martin, M.D.,* John L. Cameron, M.D.,*
Charles J. Yeo, M.D.,* Mark A. Talamini, M.D.,* Sunjay Kaushal, B.S., Ph.D.,*
JoAnn Coleman, M.S., C.R.N.P.,* Anthony C. Venbrux, M.D.,t
Scott J. Savader, M.D.,t Floyd A. Osterman, M.D.,t and Henry A. Pitt, M.D.*
From the Departments of Surgery* and Radiology, t The Johns Hopkins Medical Institutions,
Baltimore, Maryland

Objective
The authors provide the results of follow-up evaluation after combined surgical and
radiologic management of 89 patients with major bile duct injuries during laparoscopic
cholecystectomy.

Summary Background Data

The incidence and mechanism of injury of major bile duct injuries during laparoscopic
cholecystectomy has been clearly defined. Furthermore, a number of series have described
the management of these injuries by surgical, endoscopic, and radiologic techniques with
excellent short-term results. Long-term follow-up data, however, are lacking in the
management of these injuries.
Methods
Data were collected prospectively on 89 patients treated at a single institution with major
bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and
July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic
cholangiography and biliary drainage. Based on the cholangiographic appearance and
clinical situation, patients were managed by either percutaneous balloon dilatation or
surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic
stenting. Follow-up was obtained by personal interview during October 1996.
Results
Two patients died without an attempt at definitive therapy. Both deaths were caused by
sepsis and multisystem organ failure present at the time of transfer to the authors'
institution. The remaining 87 patients were managed initially by either balloon dilatation (N
= 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and
still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon
dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52
patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months)

459

460

Lillemoe and Others

Ann. Surg. * May 1997

showed a success rate of 92%. All failures were managed successfully by either surgical
reconstruction or balloon dilatation.

Conclusions
Major bile duct injuries can be managed successfully by combined surgical and radiologic
techniques. This series provides, for the first time, significant follow-up on a large number
of patients with overall success rates of 64% after balloon dilatation and 92% after surgical
reconstruction. The combination of surgery and balloon dilatation resulted in a successful
outcome in 100% of patients treated.

Laparoscopic cholecystectomy has altered dramatically

the management of patients with cholelithiasis. This procedure has rapidly gained acceptance as the treatment
of choice for most patients with symptomatic gallstones
because of the minimal pain and disability associated with
the procedure. However, compared to open cholecystectomy, the incidence of bile duct injury appears to be
increased, resulting in significant morbidity, high financial costs, and a major increase in litigation.'`' In the past
few years, the incidence4-'0 and the mechanisms2" 1-13 of
bile duct injury during laparoscopic cholecystectomy
have been well defined. A number of series describing
the management of bile duct injuries after laparoscopic
cholecystectomy by surgical,'2"','114-8 endoscopic,1821
and percutaneous techniques22'23 have been reported with
excellent short-term results. At this point, however, longterm follow-up data are lacking. The goal of this report
is to evaluate the outcome of combined surgical and radiologic management of major bile duct injuries after laparoscopic cholecystectomy with respect to long-term followup.

CLINICAL MATERIAL AND METHODS

Data were collected prospectively on all patients treated
at The Johns Hopkins Hospital for major bile duct injuries
before July 1, 1996. All patients had undergone laparoscopic cholecystectomy for treatment of benign biliary
tract disease. Major bile duct injuries included transections or partial lacerations of the common hepatic or common bile duct or major segmental ducts injured at the
porta hepatis. Cystic duct leaks or bile leaks from the
gallbladder bed after laparoscopic cholecystectomy were
excluded. Bile duct injuries after open cholecystectomy
and other upper abdominal operations were also excluded.
A total of 89 patients were managed during this period.
Presented at the 108th Annual Session of the Southern Surgical Association, December 1-4, 1996, Palm Beach, Florida.
Address reprint requests to Keith D. Lillemoe, M.D., The Johns Hopkins
Hospital, 600 North Wolfe Street, Blalock 603, Baltimore, MD
21287.
Accepted for publication December 13, 1996.

In seven patients (7.9%), the injury occurred during laparoscopic cholecystectomy at The Johns Hopkins Hospital,
whereas the remaining 82 patients were referred after
injury at an outside hospital. The initial management of
all the patients referred with a bile duct injury consisted
of a percutaneous transhepatic cholangiogram and placement of percutaneous biliary catheters. In those patients
with injuries at or near the hepatic bifurcation, both the
right and left hepatic ductal systems were accessed with
transhepatic catheters. In patients with ongoing biliary
leaks, percutaneous drainage of bile collections or ascites
was also performed as indicated. It is our practice in such
patients to control the biliary leak and associated sepsis
and then allow a period for resolution of the associated
inflammation. In many cases, after control of the bile
leak, the patient was discharged to home and returned for
definitive repair at a later date.
In those patients in whom biliary-enteric continuity was
intact and percutaneous dilatation and stenting was an
option, the decision to pursue this alternative versus surgical repair was based on the clinical assessment of the
surgeon and interventional radiologist. If the option of
percutaneous dilatation and stenting was chosen, the need
for repeat dilatation, the length of stenting, and the decision to abandon this technique in favor of surgical reconstruction again was based on the clinical judgment of the
treating surgeon and radiologist.
Surgical management consisted of a Roux-en-Y hepaticojejunostomy. All procedures were performed electively with one to three biliary catheters placed before
surgery to facilitate the operative procedure.24 After identification and mobilization of the proximal hepatic duct,
the preoperative catheters were exchanged for larger soft
silastic stents. A Roux-en-Y limb of jejunum, 50 to 60
cm in length, was created, and an end-to-side hepaticojejunostomy was performed with the stents placed through
the anastomosis.
The anastomoses were performed routinely with interrupted absorbable suture with the Roux limb placed in a
retrocolic position. The perianastomotic area was drained
with closed suction drains. In the immediate postoperative
period, the stents were left to external drainage. At postoperative day 4 or 5, a cholangiogram was performed,

Follow-up After Laparoscopic Bile Duct Injury

Vol. 225 * No. 5

461

35

25

30
20

25

15n

20
0

15

10
5

< 29

*up to July 1, 1996

Figure 1. Year of presentation of major bile duct injuries after laparoscopic cholecystectomy (* represents through July 1, 1996).

and if the study was satisfactory, the stents were internalized, and the patient's hospital course was completed as
directed by the surgical staff. The silastic stents were
changed routinely on an outpatient basis every 2 to 3
months. The length of postoperative stenting was determined by the treating surgeon based on the clinical scenario, the location of the injury, and the follow-up cholangiographic appearance. In most patients, a biliary Whitaker study25 and 2-week clinical trial with the stent
positioned above the anastomosis were completed before
stent removal.
A patient's treatment was considered complete at the
time of removal of all biliary stents. The length of followup was considered from the time of the patient's definitive
surgical or radiologic procedure. Follow-up evaluation
results were obtained by review of the patient's Johns
Hopkins Hospital and Outpatient Center medical records
and/or by personal telephone interview conducted during
October 1996. Outcome was assessed subjectively by history with symptoms of abdominal pain, fever, chills, and
jaundice being noted. The results of any diagnostic evaluation or therapeutic procedures performed after completion of the treatment were recorded and confirmed by
hospital records.
Patients' current status was rated subjectively as excellent if they had no symptoms attributable to their biliary
tract injury or reconstruction and rated good if mild symptoms, not requiring invasive investigation or treatment,
were present. Patients classified as either excellent or
good were considered to be a treatment success. Patients
were considered to be a treatment failure if a second
therapeutic procedure, either surgical or radiologic, was
necessary to treat ongoing symptoms or stricture recurrence. These definitions were consistent with an earlier
report from this institution.26
Statistical comparisons were made using Student's t
test and Fisher's exact test as appropriate. Actuarial suc-

30-39

40-49

50-59

60-69

>70

Age in Years
Figure 2. Age distrbution of patients with major bile duct injuries after

laparoscopic cholecystectomy.
cess rates were analyzed by the Mantel-Cox technique. A
p value of <0.05 was considered statistically significant.

RESULTS
Patient Characteristics, Prior
Management, and Presentation
Eighty-nine patients with major bile duct injuries have
been treated at The Johns Hopkins Hospital since the
initial patient was referred in August 1990 (Fig. 1). Seventy-two patients (81%) were female. The average age
of the patients was 41.2 years (range, 22-78 years; Fig.
2). Eighty-two patients (92.9%) had undergone laparoscopic cholecystectomy at an outside hospital and were
referred with a presumed or confirmed bile duct injury
(Table 1). In 26 patients (31%), the bile duct injury had
been recognized at the time of laparoscopic cholecystec-

Table 1. PRIOR MANAGEMENT OF 82

PATIENTS REFERRED WITH MAJOR BILE
DUCT INJURIES
Management

No. (%)

Injury recognized at time of laparoscopic

cholecystectomy
Repair at initial operation
End-to-end ductal
Hepaticojejunostomy
Injury recognized in postoperative period
Attempt at repair pror to referral
End-to-end ductal
Hepaticojejunostomy
Exploratory laparotomy for bile leak without repair
Total prior attempts at repair
End-to-end ductal
Hepaticojejunostomy
Total prior laparotomy

26 (31)
26 (100)
14 (54)
12 (46)
56 (69)
18 (32)
6 (33)
12 (67)
9 (16)
44 (54)
20 (45)
24 (55)
53 (65)

462

Lillemoe and Others

tomy, and the patient was converted to an open procedure.

Management at that time consisted of an end-to-end primary ductal anastomosis in 14 (54%) of the 26 patients,
whereas in the other 12 patients, a biliary-enteric anastomosis was constructed. In 56 patients, the injury was not
recognized at the time of laparoscopic cholecystectomy.
In 18 of these patients, at least 1 attempt at biliary reconstruction was made before referral. These procedures included 6 end-to-end primary repairs and 12 biliary-enteric
reconstructions. One patient had undergone two laparotomies for attempt at repair. In that patient, a hepaticojejunostomy was constructed when an injury was recognized
at the time of laparoscopic cholecystectomy, followed 1
week later by a second laparotomy in an attempt to repair
an ongoing biliary leak.
Nine additional patients had undergone laparotomy for
a biliary leak with external drainage without attempt at
reconstruction. In one patient, two laparotomies were performed and in another patient, a partial left hepatic lobectomy was performed for hepatic ischemia due to a concomitant vascular injury. In total, 44 (54%) of 82 patients
referred from outside hospitals had undergone an attempt
at repair, whereas 53 (65%) of the 82 patients had undergone at least 1 laparotomy in an attempt to manage the

injury.
The interval from laparoscopic cholecystectomy to referral to The Johns Hopkins Hospital ranged from 1 day
to 48 months with a mean of 7.7 months for all 82 patients
referred. The interval was < 1 month in 35 patients (43%)
and longer than 12 months in 13 patients (16%). In 31
patients (38%), an ongoing biliary leak (bile ascites or
peritonitis, a biloma or abscess, or an external fistula)
was present at the time of referral. In 30 patients (37%),
obstructive jaundice was the primary reason for referral,
whereas in 18 patients (22%), cholangitis was the major
indication. All patients referred with cholangitis had undergone an attempt at biliary reconstruction before referral. In the remaining three patients, a biliary stent (two
percutaneous transhepatic and one endoscopic) had been
placed after a cholangiogram, which had showed a biliary
injury. These patients were referred without active cholangitis or jaundice for definitive management of the in-

jury.
Seven patients underwent biliary reconstruction after
laparoscopic cholecystectomy performed at Johns Hopkins. In five of these seven patients (71%), the injury was
recognized at the time of laparoscopic cholecystectomy,
and the patient was converted to an open procedure. In
four patients, reconstruction with a Roux-en-Y hepaticojejunostomy with intraoperative placement of transhepatic
silastic stents (one stent, three patients; two stents, one
patient) was performed. In the fifth patient, a primary endto-end ductal anastomosis over a T-tube was completed.
Jaundice developed in the sixth patient in the early postop-

Ann. Surg. * May 1997

erative period, who then underwent percutaneous transhepatic cholangiography, which showed complete obstruction of the common hepatic duct. A transhepatic biliary
catheter was placed, and definitive repair was performed
during the same hospitalization. The final patient presented with obstructive jaundice 3 months after a laparoscopic cholecystectomy performed for acute cholecystitis.
Her initial operative procedure and postoperative course
had been uncomplicated. At the time of her presentation,
she underwent a percutaneous transhepatic cholangiogram, and a Roux-en-Y hepaticojejunostomy was performed for a bile duct stricture.

Management
Percutaneous transhepatic cholangiography was performed and percutaneous biliary catheters were placed
shortly after admission in all patients referred with suspected bile duct injuries. In 31 patients (38% of patients
referred), an ongoing biliary leak was shown. In those
patients without prior external drainage of the leak, percutaneous drainage of bile ascites or a bile collection was
performed. In only one patient was early operation necessary to drain an infected bile collection.
There were two deaths in the series for an overall mortality of 2.2%. Both patients were older men (ages 62
and 72) who were septic with multisystem organ failure
secondary to ongoing biliary leaks at the time of transfer
to The Johns Hopkins Hospital. The first patient had undergone a hepaticojejunostomy and a second laparotomy
to repair an ongoing bile leak before referral. The second
patient had undergone two laparotomies for intra-abdominal sepsis due to a bile leak, but no biliary reconstruction
had been attempted. Both patients underwent successful
percutaneous transhepatic cholangiography and placement of biliary catheters, and the biliary leak appeared to
be controlled. No intra-abdominal collections were seen
on computed tomogram scan. Both patients died from
multisystem organ failure without a surgical procedure
being performed. In all other patients, the leak and associated biliary sepsis was controlled. Thirteen patients (45%)
presenting with a bile leak eventually were discharged
after referral and subsequently readmitted for definitive
surgical reconstruction at a mean of 4.7 weeks (median,
5 weeks; range, 2-6 weeks). There were no deaths in
any of the 87 patients undergoing definitive management
at The Johns Hopkins Hospital either by surgical reconstruction or percutaneous dilatation during the immediate
post-treatment period or throughout the follow-up period.
In 28 (32%) of the 87 surviving patients, percutaneous
dilatation and stenting was performed as the initial attempt at definitive management (Table 2). All 28 patients
had undergone a prior attempt at bile duct repair, therefore
representing 64% of patients referred with a prior biliary

Follow-up After Laparoscopic Bile Duct Injury

Vol. 225 No. 5

-

Table 2. PREVIOUS REPAIR,

PRESENTING SYMPTOMS, LEVEL OF
OBSTRUCTION, AND USE OF STENTS
Balloon

[no. (%)]

Surgical
Reconstruction
(N = 59)
[no. (%)]

28* (100)
11 (39)
17 (61)

15 (25)
9 (60)
6 (40)

Dilatation
(N = 28)
Previous repair
End-to-end ductal
Biliary-enterc
Presenting symptoms
Jaundice
Biliary leak

Cholangitis
None
Recognized at laparoscopic
cholecystectomy
Level of obstruction
Bismuth 1
Bismuth 2
Bismuth 3
Bismuth 4
Bismuth 5
Isolated RHD
Use of stents (no.)
1
2
3

Dilatations (no.)
1
2
3+

11
8
8
1

(39)
(29)
(29)
(4)

21 (36)
21 (36)
10 (17)
2 (3)
5 (8)

6t (21)
12 (43)
6 (21)
3 (11)
1 (4)

3 (5)
20 (34)
21 (36)
7 (12)
3 (5)
5 (8)

15 (54)
1 1 (39)
2 (7)

20 (34)
36 (61)
3 (5)

18 (64)
8 (29)
2 (7)

463

repairs (60%) and six hepaticojejunostomies (40%).

Twenty-one (36%) of the 59 patients presented with a
biliary leak, 21 patients (36%) presented with obstructive
jaundice, 10 (17%) with cholangitis, and 2 (3%) were
asymptomatic after stenting at an outside hospital. In five
patients, the duct injury was recognized during surgery
at the time of laparoscopic cholecystectomy at Johns Hopkins. The interval from injury to management (excluding
intraoperatively recognized injuries) ranged from 1 day
to 48 months (mean, 6.3 months; median, 1 month). The
Bismuth level of injury and the number of stents used
during the reconstruction are listed in Table 2.
The two groups of patients undergoing balloon dilatation and surgical reconstruction were similar by most parameters. Patients undergoing balloon dilatation were
more likely to have undergone a previous attempt at repair
(p < 0.001) and to have a lower (Bismuth 1) level of
injury (p < 0.05).
The length of postoperative stenting was determined
in all patients and was defined as short-term (<4 months),
intermediate (between 4 and 9 months), and long-term (9
months or longer). In seven patients, all <1 year after
surgery, the stents are still in position and therefore the
total length of stenting cannot be determined. In 6 (12%)
of the remaining 52 patients, the length of stenting was
classified as short-term, in 11 patients (21%), the stenting
was continued for an intermediate period, and in 35 patients (67%), the long-term stenting was maintained for
longer than 9 months. The longest period of postoperative
stenting was 14 months.

RHD = right hepatic duct.

p < 0.001 vs. surgical repair.
t p < 0.05 vs. surgical repair.

Outcome

reconstruction. These prior repairs consisted of an endto-end duct repair in 11 patients (39%) and a hepaticojejunostomy in 17 patients (61%). Eleven (39%) of the 28
patients presented with obstructive jaundice, 8 patients
(29%) with a biliary leak, and 8 (29%) with episodes of
cholangitis. One patient was asymptomatic after percutaneous drainage at an outside hospital. The interval from
injury to referral ranged from 1 week to 40 months (mean,
7.8 months; median, 2 months). Twelve patients were
referred at 1 month or less after injury. The level of the
injury with respect to the confluence of the hepatic ducts,
as described by Bismuth,27 is listed in Table 2. The number of stents and the number of dilatations performed also
are included in Table 2.
In 59 (68%) of the surviving 87 patients, the initial
definitive management consisted of surgical biliary reconstruction. Only 15 (25%) of these patients had undergone
an attempt at repair before treatment at Johns Hopkins.
The previous repairs consisted of nine end-to-end ductal

Current follow-up as of October 1996 is available for

86 of 87 surviving patients. The follow-up period for all
patients ranges from 4 to 75 months (mean, 31.4 months;
median, 28.5 months). At this time, 10 patients (11%)
have not completed their course of treatment and have
biliary stents in place. Three patients have undergone
percutaneous biliary dilatation with their initial dilatation
4, 9, and 10 months ago. Seven patients not completing
treatment have undergone biliary reconstruction and currently are 4, 5, 6, 7, 8, 8, and 9 months after the procedure.
The only patient lost to follow-up was doing well when
last seen as an outpatient 4 months after stent removal
and 16 months after a hepaticojejunostomy.
The current status of the 25 patients who have completed therapy after balloon dilatation as their initial therapy has been excellent (N = 12) and good results (N =
4) in 16 patients, representing an overall success rate of
64% (Table 3). The actuarial success for balloon dilatation as an initial treatment is shown in Figure 3. The
range of follow-up is from 4 to 64 months with a mean
follow-up of 27.8 months and a median follow-up of 23

464

Lillemoe and Others

Ann. Surg. * May 1997

Table 3. OUTCOME FOLLOWING INITIAL

TREATMENT OF MAJOR BILE
DUCT INJURY*

Number
Outcome
Success
Excellent
Good
Failure
Predictors of outcome (no. of
failures/total patients)
Previous repair
End-to-end ductal
Hepaticojejunostomy
None
Presenting symptom
Jaundice
Biliary leak
Cholangitis
Bismuth class
1 and 2
3, 4, 5
RHD
Interval to referral
'1 month
>1 month

Balloon
Dilatation

Surgical
Reconstruction

25

52

16
12
4
9

(64%)t
(48%)t
(16%)
(36%)t

48
41
7
4

(92%)
(79%)
(13%)
(8%)

9/25
4/10
5/15

3/12
2/8
1/4
1/40**

1/9
6/8
2/7

3/21
2/27
0/9

3/16

6/811

1/20
2/27
1/5

7/11
2/14

1/16
3/36

RHD = right hepatic duct.

Includes only 77 patients completing treatment.
t p < 0.002 vs. surgical reconstruction.
t p < 0.01 vs. surgical reconstruction.
p < 0.05 vs. jaundice/cholangitis.
p < 0.05 vs. Bismuth 1 and 2.
p < 0.05 vs. -1 month.
p < 0.05 vs. previous repair.
*

months. There have been nine failures of percutaneous

dilatation for a 36% failure rate. Factors potentially predicting outcome are listed in Table 3. In five of these
patients, the original outside repair had been a hepaticojejunostomy, whereas in the four other failures, an end-toend ductal anastomosis had been performed. Presentation
with a bile leak, a Bismuth classification of level 3 injury
or higher, and an interval to referral of <1 month appeared to be predictors of a poor outcome. The interval
from initial dilatation to failure ranged from 4 to 17
months (mean, 8.2 months; median, 6 months). Eight of
the nine patients subsequently have undergone surgical
biliary reconstruction at Johns Hopkins. The ninth failure
was managed by repeat percutaneous dilatation at a center
closer to his home with excellent results.
The current status of the 52 patients completing therapy
after surgical reconstruction as the initial management is
an excellent outcome in 41 patients and good results in
7 patients for an overall success rate of 92% (48 of 52

patients) (Table 3). The actuarial success for surgical repair as an initial therapy is shown in Figure 3. The success
rate for surgical repair was significantly better than for
balloon dilatation (p < 0.002). The range of follow-up is
from 4 to 75 months with a mean follow-up of 33.4
months and a median follow-up of 29 months. There have
been four failures of surgical management occurring at
8, 13, 21, and 27 months. Factors potentially predicting
outcome are listed in Table 3. Three of the four failures
had undergone a repair before referral to Johns Hopkins.
The Bismuth classification was level 2 in one patient and
level 4 in two patients. The remaining patient had an
injury that was an isolated transected right hepatic duct
and had presented with a bile leak. Three of the four
failures were managed by percutaneous dilatation with
excellent or good results in all three patients with followup of 17, 22, and 39 months. The fourth patient underwent
a revision of his hepaticojejunostomy and has had an
excellent result at 22 months of follow-up.
The length of postoperative stenting was of intermediate length in two of the patients who did not respond to
surgical repair and long-term in the remaining two patients. The length of stenting was not significant as a
predictor of outcome.
As discussed above, all patients who failed their initial
management with either balloon dilatation or surgical reconstruction currently are considered a treatment success
after a second procedure. Therefore, of the 77 patients
who have completed therapy, including both primary
management and additional treatment for an unsuccessful
initial result, a successful outcome has been achieved in
100% of patients. In 28 patients who completed therapy
after balloon dilatation, performed as either initial therapy
or as therapy after a failed hepaticojejunostomy performed at this institution, an overall success rate of 68%
was seen (mean follow-up, 27.7 months; median followup, 22.5 months). Similarly, a total of 61 patients have

Surgical Repair
0.9 .

UM

C.

--

0.8

p<O.002

0.7 .

--

Balloon Dilatation

0.6 .

0.5 .
A

I Ij

24

1A

36

-2

AO
48

11,n
60

11,

Months
Figure 3. Actuarial success rate for surgical repair and balloon dilatation as the initial treatment for bile duct injuries after laparoscopic cholecystectomy. The difference is highly statistically significant (p < 0.002).

Vol. 225 No. 5

-

completed therapy after surgical reconstruction either as a

primary therapy or after failed dilatation with a successful
outcome in 93% (mean follow-up, 33.2 months; median
follow-up, 29 months). The overall success rate associated
with surgical repair was statistically better than that observed with percutaneous dilatation (<0.002).

DISCUSSION
Since its introduction in the late 1980s, laparoscopic
cholecystectomy has gained widespread acceptance
among surgeons and the public and has essentially replaced open cholecystectomy as the treatment of choice
for symptomatic gallstones. Compared with open cholecystectomy, laparoscopic cholecystectomy is associated
with less postoperative pain, a shorter hospital stay, earlier
return to work, and a better cosmetic outcome.28 Unfortunately, compared to open cholecystectomy, laparoscopic
cholecystectomy appears to be associated with an increase
in the incidence of bile duct injuries. Before the introduction of laparoscopic cholecystectomy, the incidence of
major bile duct injury was considered to be 2 to 3 injuries
per 1000 procedures.13'2930 Roslyn et al.30 analyzed the
results of more than 42,000 open cholecystectomies performed in the United States in 1989 and found the incidence of bile duct injury to be 0.2%. In a review by
Strasberg et al.'3 of more than 25,500 open cholecystectomies reported in the literature since 1980, major bile duct
injury was reported in 0.3% of patients.
The incidence of bile duct injury during laparoscopic
cholecystectomy has varied from large single institution
series without a single biliary injury3l-34 to surveys encompassing thousands of patients from multiple hospitals with
the incidence of injury reported as high as 0.9%.4- 1035
The review by Strasberg et al.'3 of more than 124,000
laparoscopic cholecystectomies reported in the literature
found the incidence of major bile duct injury to be 0.5%.
It had been hoped, as most surgeons passed through the
"learning curve" of laparoscopic cholecystectomy, that
the incidence of injury would decline. Unfortunately, a
recent "steady-state" report of more than 10,000 cases at
U.S. military institutions by Wherry and colleagues'0 has
shown no significant improvement over the initial report
from the same institutions.9
As experience in the management of laparoscopic bile
duct injuries has been gained, the mechanisms of injury
have been established. Misidentification of anatomy appears to be the most common cause of laparoscopic bile
duct injury. The most common scenario, initially described by Davidoff et al." at Duke as the "classic"
injury, involves mistaking the common bile duct for the
cystic duct. The structure then is clipped and divided.
Further retraction of the gallbladder will lead to a second
higher injury with division of the common hepatic duct

Follow-up After Laparoscopic Bile Duct Injury

465

often as it approaches the bifurcation. This second ductal

injury often is described in the operative note as being a
"second cystic duct" or "an accessory duct." In some
cases, the right hepatic artery also is injured during this
process. If the proximal hepatic duct is not secured adequately with clips, a bile leak develops with the patient
presenting in the early postoperative period with bile ascites or peritonitis. This injury is particularly devastating
in that a complete transection of the biliary tree virtually
removes any possibility of nonoperative management by
either endoscopic or transhepatic technique and mandates
the need for surgical reconstruction of the biliary tree to
establish biliary-enteric drainage. In a series also reported
from Duke by Branum et al.,'6 this classic injury occurred
in 24 (63%) of 38 patients. Other less common mechanisms of injury include a "tenting injury" in which the
common bile duct is pulled laterally at the time of occlusion of the cystic duct and caught in the clip, thermal
injuries due to injudicious use of cautery or laser, excessive application of clips to control bleeding in the area
of the triangle of Calot, and, finally, injuries to an aberrant
or low-inserting right hepatic duct.
Regardless of the nature of the injury, the majority
of biliary injuries are not recognized during the initial
laparoscopic cholecystectomy. In their initial series, Davidoff et al." from Duke found that in all 12 patients with
major bile duct injuries, the injury was not recognized at
the time of laparoscopic cholecystectomy. In the current
series, fewer than one third of injuries were recognized
at the original operation, although in five of seven patients
at our own institution, the injury was recognized and
repaired successfully at the original laparoscopic procedure. The failure to recognize an injury at the time of
laparoscopic cholecystectomy and the high incidence of
bile leakage in the postoperative period with resultant
sepsis and associated periportal inflammation can complicate greatly the management of these patients.
The management of laparoscopic bile duct injuries has
been well defined by a number of authors." 2""1'14-23 We
believe that a patient with a suspected major bile duct
leak should not undergo immediate operation but rather
be evaluated completely before operative management
is considered. A computed tomogram scan is useful in
showing the presence of an intraperitoneal bile leak by
displaying either bile ascites or a "biloma." Endoscopic
retrograde cholangiography usually is readily available to
confirm the presence of an injury. However, in the classic
injury involving bile duct transection, the retrograde cholangiogram will only show a "cutoff' of the common
bile duct below the level of the cystic duct. It is essential,
therefore, that percutaneous transhepatic cholangiography
be performed to define the exact location and nature of
the injury as well as to define the anatomy of the proximal
biliary tree, which will be used for reconstruction. Percu-

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Lillemoe and Others

taneous transhepatic biliary catheters should be placed to

control the bile leak, and percutaneous drainage of the
intraperitoneal bile collection should be performed as indicated. This management usually will result in immediate improvement of the patient. In many cases, this management will allow the patient to be discharged to home
for a period of a few weeks before surgical repair to allow
resolution of the inflammation and adhesions associated
with the bile leak. The standard operation for reconstruction of a major bile duct injury after laparoscopic cholecystectomy is a Roux-en-Y hepaticojejunostomy. The
transection of the bile duct and associated resection of a
segment of the duct usually precludes any attempt at primary end-to-end ductal anastomosis.
Using this or a similar management course, a number
of centers have reported excellent early results in the
management of laparoscopic bile duct injuries. 2,1 '4-21
In most series, surgical management has been necessary
in the majority of cases. Selected patients, however, have
been reported who have been managed successfully entirely by endoscopic or percutaneous technique. 18-23 Asbun et al.2 at The Lahey Clinic reported their preliminary
experience in the management of 15 repairs with a successful outcome in all patients at a median follow-up of
10 months.2 In contrast, of the 38 patients with complex
major bile duct injuries managed at the Duke Medical
Center, 5 patients required reoperation and 1 patient required balloon dilatation for persistent or subsequent
problems.'6 Long-term outcome is not available in either
of these series.
Three other series stand out for both the number of
patients treated and their analysis of results. Perhaps the
best analysis of data from a large number of patients is
that provided by Stewart and Way36 who analyzed the
treatment of 88 patients who sustained bile duct injuries
during laparoscopic cholecystectomy. In this report, the
records of 85 patients who underwent a total of 112 biliary
repairs were reported. The series included 64 reparative
operations performed by the primary surgeon or a surgeon
of comparable experience as well as 46 surgical reconstructions performed on 45 patients by tertiary care biliary
surgeons. Four factors determined the success or failure
of treatment in their series. These factors were the performance of preoperative cholangiography, the choice of surgical repair, the details of the operative technique, and
the experience of the surgeon performing the repair. The
importance of preoperative delineation of the anatomy
is defined clearly, because 96% of procedures in which
cholangiograms were not obtained before surgery were
unsuccessful and 69% of repairs were unsuccessful when
the cholangiographic data were incomplete. When cholangiographic data were complete, the initial repair was successful in 84% of patients. The type of repair also was of
significant importance in influencing outcome. A primary

Ann. Surg. May 1997

-

end-to-end ductal repair over a T-tube was unsuccessful

in all of those patients in which a complete transection
of the bile duct had taken place, whereas 63% of Rouxen-Y hepaticojejunostomies were successful. Dilatation
and stenting was unsuccessful as a primary treatment in
all 3 patients in whom it was performed and successful
in only 7 (27%) of 26 patients in whom it was attempted
after previous operative repair. Attempts at repair performed by the primary surgeon were successful in only
17% of cases and in no case was a secondary repair
successful. In those patients in which the first repair was
performed by a tertiary care biliary surgeon, a 94% success rate was obtained.
A multicenter report by Woods et al.'8 from the Virginia Mason Clinic in Seattle, Washington, the Lahey
Clinic in Burlington, Massachusetts, and the Mayo Clinic
in Rochester, Minnesota, have reported the management
of 81 patients with biliary tract injuries occurring during
laparoscopic cholecystectomy.18 This series included 66
patients with major ductal strictures, leaks, or transections. In this report, a similar high rate of failure (94%
for biliary-enteric bypass) was observed after repair outside of the referral center. Conversely, all patients managed by reoperation (N = 29) at the tertiary center and
10 of 11 patients managed by endoscopic stenting had a
successful result. Unfortunately, in neither the series by
Stewart and Way36 or the multicenter report by Woods
et al.'8 was long-term follow-up provided.
Perhaps the longest follow-up available after the management of major bile duct transections is reported by
Bergman et al.2' from the Netherlands in which 15 patients sustaining major bile duct injury were reconstructed
with a Roux-en-Y hepaticojejunostomy. At a median follow-up of 25 months (range, 6-38 months) 5 (33%) of
the 15 patients required subsequent transhepatic balloon
dilatation or reconstruction with a secondary hepaticojejunostomy.
A number of series have provided excellent long-term
results in the management of bile duct strictures occurring
before the laparoscopic era.26'3742 In most series, success
ful outcomes are reported in 80% to 95% of patients.
Whether the results of repair of bile duct strictures after
open cholecystectomy are transferable directly to the patients sustaining laparoscopic bile duct injuries is unclear.
It has been suggested that laparoscopic bile duct injuries
may have a less satisfactory outcome because of both the
more complex nature of many of the injuries and the
frequent association with significant inflammation and
fibrosis secondary to the bile leakage. Furthermore, the
high percentage of failed operations performed before
referral to a tertiary biliary tract surgical center may lead
to a poorer outcome.
The results of the current analysis provide, for the first
time, significant follow-up in a large number of patients

Vol. 225 * No. 5

Follow-up After Laparoscopic Bile Duct Injury

467

with laparoscopic bile duct injuries undergoing both surgical reconstruction and nonoperative percutaneous balloon dilatation. These patients represent a heterogeneous
group of patients, including those in whom the injury
took place at our own institution, patients who were referred before any attempt at repair, and patients referred
after attempts at biliary reconstruction. In total, 54% of
the patients referred from outside hospitals had undergone
an attempt at repair before referral. Active ongoing biliary
leak was present in 38% and sepsis due to cholangitis
was present in 22% of patients at the time of referral to
our institution. The patients referred to our center with
injuries were all managed with combined radiologic and
surgical management. Preoperative imaging of the biliary
tree by way of the percutaneous transhepatic route and
placement of biliary stents were performed in all patients.
Subsequent management was based on the clinical scenario and cholangiographic appearance with patients selected accordingly for either primary management by radiologic balloon dilatation or surgical repair.
Follow-up to the present time was obtained by direct
patient contact in 86 of 87 surviving patients and ranged
from 4 to 75 months with a mean of 31.4 months and a
median of 28.5 months. Primary nonoperative management with balloon dilatation was associated with an overall success rate of 64%. In contrast, primary surgical management with hepaticojejunostomy was associated with a
success rate of 92%. Although this difference was statistically significant, we do not conclude that this study directly favors one treatment option over the other. Patients
undergoing balloon dilatation all had undergone a previous attempt at repair, and in a number of the cases, the
balloon dilatation option was aborted in favor of surgery
before completion of a full treatment course. Fortunately,
the 13 failures (9 dilatation failures and 4 surgical failures) were all salvaged by secondary management. Therefore, using combined surgical and radiologic management, 100% of patients have achieved a successful outcome at the time of this evaluation.
Although the follow-up in this series is substantial,
continued surveillance and follow-up will be necessary.
Pitt et al.37 in their analysis of factors influencing the
outcome after repair of postoperative bile duct strictures
in the prelaparoscopic era have reported that only 68%
of recurrent strictures will have developed by 3 years
after repair. If this analysis, derived from open cholecystectomy data, can be applied to the current series, the
long-term success rate of balloon dilatation would be approximately 50% and of surgical reconstruction would be
86%. These projected results are almost identical to those
reported previously from this institution from the open

influencing outcome. Three of the four surgical failures

did occur after a failed early repair at an outside institution, and two of the four patients required reconstruction
to be performed above the level of the hepatic duct bifurcation. Our analysis would, however, suggest that patients
presenting with an ongoing bile leak, referred at 1 month
or earlier after injury, and patients with injuries located
at the level of the hepatic duct bifurcation or higher are
more likely to fail attempts at balloon dilatation.
The significance of delayed management of patients
with laparoscopic bile duct injuries can be evidenced by
the fact that there were two deaths in the series. In both
patients, ongoing biliary leaks persisted despite two surgical interventions having been performed at the initial hospital for each patient. Both patients were older and had
persistent sepsis and multisystem organ failure at the time
of transfer. Despite achieving adequate percutaneous
drainage of the biliary tree, as well as drainage of all
potential foci of intra-abdominal sepsis, the patients died
because of the advanced state of their disease despite
maximal supportive care.
Finally, the results of this series, as well as those of
previous reports,1836 would suggest that success rates in
excess of 90% can be achieved at tertiary referral centers
for complex biliary tract surgery. These results far exceed
those available after repair of these injuries by less experienced surgeons, 136 although it could be argued that the
true denominator is not known because successful repairs
outside tertiary referral centers often go unreported. It
would appear, however, as with other complex surgical
procedures,43'" that major bile duct injuries can be managed best at centers with a high-volume experience.
In conclusion, the optimal management of patients with
laparoscopic bile duct injury requires a multidisciplinary
approach. Percutaneous transhepatic cholangiography to
define the proximal anatomy and the placement of transhepatic biliary catheters to relieve biliary obstruction or
control biliary leaks is the first step in management. The
decision to proceed with percutaneous balloon dilatation
versus operative management is determined by the nature
and location of the injury and the clinical scenario. This
study provides, for the first time, follow-up evaluation
results in a significant number of patients undergoing both
treatment regimens. With mean follow-ups in excess of
21/2 years, percutaneous balloon dilatation is associated
with an overall success rate of 64% and biliary reconstruction with a Roux-en-Y hepaticojejunostomy is associated
with an overall success rate of 92%. The combined surgical and radiologic management should result in a successful outcome after laparoscopic bile duct injuries in virtually all patients.

cholecystectomy era. 26

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Discussion
DR. WILLIAM C. MEYERS (Worcester, Massachusetts): Thank
you, Dr. Cameron, Dr. Copeland, Members, and Guests. I agree
with you, Dr. Cameron, that you've assembled the finest group
of gastrointestinal surgeonms in the country and the continent.